Slouched posture is very common and tends to increase access to helpless, hopeless, powerless and depressive thoughts as well as increased head, neck and shoulder pain. Described are five educational and clinical strategies that therapists can incorporate in their practice to encourage an upright/erect posture. These include practices to experience the negative effects of a collapsed posture as compared to an erect posture, watching YouTube video to enhance motivation, electromyography to demonstrate the effect of posture on muscle activity, ergonomic suggestions to optimize posture, the use of a wearable posture biofeedback device, and strategies to keep looking upward. When clients implement these changes, they report a more positive outlook and reduced neck and shoulder discomfort.

Background

Most people slouch without awareness when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016) as shown in Figure 1. Many clients in psychotherapy and in biofeedback or neurofeedback training experience concurrent rumination and depressive thoughts with their physical symptoms. In most therapeutic sessions, clients sit in a comfortable chair, which automatically creates a posterior pelvic tilt and encourages the spine to curve so that the client sits in a slouched position. While at home, they sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web.

Figure 1. (A). Employee working on his laptop. (B). Boy with ADHD being trained with neurofeedback in a clinic. (C). Student looking at cell phone. When people slouch and look at the screen, they tend to slouch and scrunch their neck.

In many cases, the collapsed position also causes people to scrunch their necks, which puts pressure on their necks that may contribute to developing headache or becoming exhausted. Repetitive strain on the neck and cervical spine may trigger a cervical neuromuscular syndrome that involves chronic neck pain, autonomic imbalance and concomitant depression and anxiety (Matsui & Fujimoto, 2011), and may contribute to vertebrobasilar insufficiency –a reduction in the blood supply to the hindbrain through the left and right vertebral arteries and basilar arteries (Kerry, Taylor, Mitchell, McCarthy, & Brew, 2008). From a biomechanical perspective, slouching also places more stress is on the cervical spine, as shown in Figure 2. When the neck compression is relieved, the symptoms decrease (Matsui & Fujimoto, 2011).

Most people are totally unaware of slouching positions and postures until they experience neck, shoulder, and/or back discomfort. Neither clients nor therapists are typically aware that slouching may decrease energy levels and increase the prevalence of negative (hopeless, helpless, powerless, or defeated) memories and thoughts (Peper & Lin, 2012; Peper et al, 2017)

Recommendations for posture awareness and training in treatment/education

The first step in biofeedback training and therapy is to systematically increase awareness and training of posture before attempting further bio/neurofeedback training and/or cognitive behavior therapy. If the client is sitting in a collapsed position in therapy, then it will be much more difficult for them to access positive thoughts, which interferes with further training and effective therapy. For example, research by Tsai, Peper, & Lin (2016) showed that engaging in positive thinking while slouched requires greater mental effort then when sitting erect. Sitting erect and tall contributes to elevated mood and positive thinking. An upright posture supports positive outcomes that may be akin to the beneficial effects of exercise for the treatment of depression (Schuch, Vancampfort, Richards, Rosenbaum, Ward, & Stubbs., 2016).

Most people know that posture affects health; however, they are unaware of how rapidly a slouching posture can impact their physical and mental health. We recommend the following educational and clinical strategies to teach this awareness.

Practicing activities that raise awareness about a collapsed posture as compared to an erect posture

Guide clients through the practices so that they experience how posture can affect memory recall, physical strength, energy level, and possible triggering of headaches.

A. The effect of collapsed and erect posture on memory recall. Participants reported that it is much easier evoke powerless, hopeless, helpless, and defeated memories when sitting in a collapsed position than when sitting upright. Guide the client through the procedure described in the article, How posture affects memory recall and mood (Peper, Lin, Harvey, and Perez, 2017) and in the blog Posture affects memory recall and mood.

B. The effects of collapsed and erect posture on perceived physical strength. Participants experience much more difficulty in resisting downward pressure at the wrist of an outstretched arm when slouched rather than upright. Guide the client through the exercise described in the article, Increase strength and mood with posture (Peper, Booiman, Lin, & Harvey, 2016) and the blog, Increase strength and mood with posture.

D. The effect of neck compression to evoke head pressure and headache sensations. In our unpublished study with students and workshop participants, almost all participants who are asked to bring their head forward, then tilt the chin up and at the same time compress the neck (scrunching the neck), report that within thirty seconds they feel a pressure building up in the back of the head or the beginning of a headache. To their surprise, it may take up to 5 to 20 minutes for the discomfort to disappear. Practicing similar awareness activities can be a useful demonstration for clients with dizziness or headaches to experience how posture can increase their symptoms.

Record EMG from muscles such as around the cervical spine, trapezius, frontalis, and masseters or beneath the chin (submental lead) to demonstrate that having the head is forward and/or the neck compressed will increase EMG activity, as shown in Figure 3.

Figure 3. Electromyographic recording of the muscle under the chin while alternating between bringing the head forward or holding it back, feeling erect and tall.

The client can then learn awareness of the head and neck position. For example, one client with severe concussion experienced significant increase in head pressure and dizziness when she slouched or looked at a computer screen as well as feeling she would never get better. She then practiced the exercise of alternating her awareness by bringing her head forward and then back, and then bringing her neck back while her chin was down, thereby elongating the neck while she continued to breathe. With her head forward, she would feel her molars touching and with her neck back she felt an increase in space between the molars. When she elongated her neck in an erect position, she felt the pressure draining out of her head and her dizziness and tinnitus significantly decrease.

Assessing ergonomics to optimize posture.

Change the seated posture of both the therapist and the client during treatment and training. Although people may be aware of their posture, it is much easier to change the external environment so that they automatically sit in a more erect power posture. Possible options include:

A. Seat insert or cushions. Sit in upright chairs that encourage an anterior pelvic tilt by having the seat pan slightly lower in the front than in the back or using a seat insert to facilitate a more erect posture (Schwanbeck, Peper, Booiman, Harvey, & Lin, 2015) as shown in Figure 4.

Figure 4. An example of how posture can be impacted covertly when one sits on a seat insert that rotates the pelvis anteriorly (The seat insert shown in the diagram and used in research is produced by BackJoy™).

B. Back cushion. Place a small pillow or rolled up towel at the kidney level so that the spine is slight arched, instead of sitting collapsed, as shown in Figure 5.

Figure 5. An example of how a small pillow, placed between the back of the chair and the lower back, changes posture from collapsed to erect.

C. Check ergonomic and work site computer use to ensure that the client can sit upright while working at the computer. For some, that means checking their vision if they tend to crane forward and crunch their neck to read the text. For those who work on laptops, it means using either an external keyboard, a monitor, or a laptop stand so the screen is at eye level, as shown in Figure 6.

The wearable biofeedback device, UpRight™, consists of a small sensor placed on the spine and works as an app on the cell phone. After calibration the erect and slouched positions, the posture device gives vibratory feedback each time the participant slouches, as shown in Figure 7.

Figure 7. Illustration of a posture feedback device, UpRight™. It provides vibratory feedback to the wearer to indicate that they are beginning to slouch.

Clinically, we have observed that clients can learn to identify conditions that are associated with slouching, such as feeling tired, thinking depressive/hopeless thoughts or other situations that evoke slouching. When people wear a posture feedback device during the day, they rapidly become aware of these subjective experiences whenever they slouch. The feedback reminds them to sit in an erect position, and they subsequently report an improvement in health (Colombo et al., 2017). For example, a 26-year-old man who works more than 8 hours a day on computer reported, “I have an improved awareness of my posture throughout my day. I also notice that I had less back pain at the end of the day.”

Integrating posture awareness and position changes throughout the day

After clients have become aware of their posture, additional training included having them observe their posture as well and negative changes in mood, energy level or tension in their neck and head. When they become aware of these changes, they use it as a cue to slightly arch their back and look upward. If possible have the clients look outside at the tops of trees and notice details such as how the leaves and branches move. Looking at the details interrupts any ongoing rumination. At the same time, have them think of an uplifting positive memory. Then have them take another breath, wiggling, and return to the task at hand. Recommend to clients to go outside during breaks and lunchtime to look upward at the trees, the hills, or the clouds. Each time one is distracted, return to appreciate the natural patterns. This mental break concludes by reminding oneself that humans are like trees.

Trees are rooted in the earth and reach upward to the light. Despite the trauma of being buffeted by the storms, they continue to reach upward. Similarly, clouds reflect the natural beauty of the world, and are often visible in the densest city environment. The upward movement reflects our intrinsic resilience and growth. –Erik Peper

Have clients place family photos and art slightly higher on the wall at home so they automatically look upward to see the pictures. A similar strategy can be employed in the office, using art to evoke positive feelings. When clients integrate an erect posture into their daily lives, they experience a more positive outlook and reduced neck and shoulder discomfort.

Compliance with Ethical Standards:

Conflict of Interest: Author Erik Peper has received donations of 15 UpRight posture feedback devices from UpRight (http://www.uprightpose.com/) and 12 BackJoy seat inserts from Backjoy (https://www.backjoy.com) for use in research. Co-authors I-Mei Lin and Richard Harvey declare that they have no conflict of interest.

This report evaluated a convenience sample of a student classroom activity related to posture and the information was anonymous collected. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight

“I feel much more relaxed and realize now how unaware I was of the unnecessary tension I’ve been holding” is a common response after muscle biofeedback training. Many people experience exhaustion, stiffness, tightness, neck, shoulder and back pain while working long hours at the computer or while exercising. As we get older, we assume that discomforts are the result of aging. You just have to accept it and live with it–grin and bear it–or you need to be more careful while doing your job or performing your hobby. The discomfort in many cases is the result of misuse of your body. Observes what happens when you perform the following experiential practice Threading the needle.

Perform this task so that an observer would think it was real and would not know that you are only simulating threading a needle.

Imagine that you are threading a needle — really imagine it by picturing it in your mind and acting it out. Hold the needle between your left thumb and index finger. Hold the thread between the thumb and index finger of your right hand. Bring the tip of the thread to your mouth and put it between your lips to moisten it and make it into a sharp point. Then attempt to thread the needle, which has a very small eye. The thread is almost as thick as the eye of the needle.

As you are concentrating on threading this imaginary needle, observed what happened? While acting out the imagery, did you raise or tighten your shoulders, stiffen your trunk, clench your teeth, hold your breath or stare at the thread and needle without blinking?

Most people are surprised that they have tightened their shoulders and braced their trunk while threading the needle. Awareness only occurred after their attention was directed to the covert muscle bracing patterns.

Hi, I'm Erik Peper, Professor of Holistic Health of San Francisco State University, President of the Biofeedback Federation of Europe, and I also maintain a private practice (www.biofeedbackhealth.org) I love exploring new ways of empowering people to optimize health and wellness. I am inspired by seeing people heal and a good cappuccino.

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